Introduction

The spontaneous epidural haematoma is a very rare situation inobstetrical patients: only some cases occured during pregnancy are reportedeach year in the literature [1-3]. It’s spontaneous when there isno traumatism, no arteriovenous malformation, no blood disorders,and no lumbar nor epidural puncture [1,4].

We present the case of spontaneous thoracic epidural haematomain a woman who had neurologic symptoms six years ago, but now at35th week of gestation symptoms and complications were strong. We’lldiscuss therefore the obstetrical and anesthetic managements of thiscomplication.

Case Report

It’s about a 26 years-old nulliparous patient, presenting at the35th week of amenorrhae. She has been married for approximately 18months. Her pregnancy is well followed and no problem is reporteduntil there.

Her history is very interesting: she brings back the concept of paraplegiainstalled at it exactly six years ago with a sensitive block, she wasconfined to bed without specialized consultation nor imaging carriedout, with a progressive recovery over two weeks, beginning on the lowelof distal parts. The patient did not report the concept of traumatismnor medicamentous cach such as aspirin or anticoagulants drugs.

She accused back pain on Thursday at 8:00 pm, she took herselfparacetamol but pain became increasingly intense on Friday.

On Saturday, at 7:00 am, she was presented without neurologicaldeficit, at the nearest hospital to her, for an intense pain with scapularirradiation. The physician prescribed analgesics to her then told her toreturn home (we had no data about the neurological examination) butthe patient did not observe any improvement.

On Saturday, at 4:00 am, she was unable to mobilize her legs, shethen decided to consult in our unit (maternity of Ibn Rochd Universityhospital of Casablanca). On admission, at 9:00 am, she was apyretic,her blood pressure was 125/74 mm Hg, her heart rate 82 beats per minute,her respiratory rate 17 breathes per minute and her oxygen saturationwas 99% in room air. She did not have proteinuria with urinaryreactive strip. The neurological examination found a conscious patientwith areflexic paraplegia, the upper sensitive level was T6-T7 (xyphoidappendix) on the right side and T4 (breast) at the left one. She had alsourinary sphincter disorders.

Obstetrical examination found a fetal heart rate at 145 beats perminute, a closed and posterior uterine cervix and a cephalic presentationwithout uterine contractions. Obstetrical Doppler did not showfetal detriment. The patient received 12 mg of betamethazone for acceleratingfetal lung maturation.

Resonance Magnetic Imaging (RMI) was performed on Monday9:00 am and showed (Figures 1 and 2) the spinal cord compressionby the haematoma; she did not have any vascular malformation, nor tumor. She was transferred at 02:00 pm into neurosurgical operatingroom: arterial line monitoring of blood pressure was performed withroutine monitoring for an elective caesarean section under general anesthesia(electrocardiogram, pulse oximetry and end tidal carbon dioxidemeasurement).

Figure 1: Cervical and thoracic MRI in T1 (sagittal) showing an epidural haematoma
compressing the spinal cord from the 2nd to the 4th thoracic vertebrae.

The patient underwent caesarean section under general anesthesia (32 hours after onset of paraplegia) followed immediately by laminectomy.

After oral administration of cimetide (anti H2 + soduim citrate)400 mg, infusion of 0.9% saline (10 ml/kg), she was preoxygenated for8 minutes. General anesthesia was started with thiopentone (6 mg/kg)and rocuronium (0.8 mg/kg); cricoid pressure was applied by the assistant,a resident maintained the head in neutral position with traction.Tracheal intubation was easily performed with a 6.5 mm armouredtube. At cesarean section, a male newborn was delivered weighing 1770g with Apgar score 7, 8 and 10 at first, 5th and 10th minute respectively.

After recovery from general anesthesia, patient was conscious andher neurological status was similar to preoperative period. She didn’trequire analgesics because of persistant sensitive block; daily rehabilitationdid not impove the neurological function.

Further RMI, realized five days after surgery, showed edema andischemia of the thoracic spinal cord; she was discharged home after18 days.

We saw the patient eleven weeks after leaving hospital, she was alwaysparaplegic and her sensitive level was T4 on the left and T6 on theright side. She always keep sphincters disorders. One year after, patientwas in the same status and lost her husband!

Discussion

Spontaneous peri-medullary compression is an extremely rare complication in pregnancy. Many situations could contribute to thishaematoma such as aretrial hypertension, vasculitis, ankylosing spondylitis,physical strain, coagulation disorders [1], angiolipoma [5],preeclampsia and hellp syndrome [6,7] and the use of low molecularweight heparin [8]. It occurs early in pregnancy [9], during second andthird trimester and in the post partum stage as well [10-12].

It is the second case of spontaneous epidural haematoma in ourobstetrical unit over twenty years, the first one [10] being published in2004. It seems that this recent case is among 20 to 30 others reported inthe english literature.

It is postulated that high venous pressure associated with pregnancymust be a contributing factor [11,12], also, pregnancy-induced structuralchanges of the vascular walls and hemodynamic changes may playa role in the pathogenesis of spontaneous spinal epidural hematoma.

The particular characterstics in this patient are:

- Firstly; the history of marked paraplegia six years ago but not diagnosed(no RMI) and recovered well after two weeks. Probably, theepidural haematoma was spontaneously resorbed. In the literature, thisfavourable evolution is very rare but not impossible [13].

- Secondly; the high delay between symptoms and decompression;in those neurological complications, the delay between the presentationand decompression is the main determining factor of the neurologicalprognosis. Many factors contributed to this delay in our casesuch as the history of the same symptoms with total recovery; the nonrecognitionof this complication by physicians and the delay betweensymptoms and the realization of RMI, that was not available in theemergency unit. In rural areas, the same evolution could be observed:no physician, no radiological imaging and probably no prehospitalcare. In Morocco, we have 33 millions of people and 50% of them livesin rural areas. However, authors observed complete neurological functionrecovery 60 hours between symptoms and decompression [12].our patient had less delay but bad outcome!

- Thirdly; anesthetic particularities: In the literature, epidural haematomaoccurs in second half of pregnancy and ceasarean section beingrealized in the first, but if patient consulted early in pregnancy, thepriority would have being laminectomy immediatly in order to evacuatethe haematoma. Neurosurgeon could perform lumbar disc surgeryin left lateral position during pregnancy to ovoid inferior cava venouscompression. At all stages of pregnancy, both anesthetic and obstetricconsiderations must be envisaged to avoid aortocaval compression, theintubation failure and the gastric contents aspirations.

In childern, when neurolological signs are not severe and not progressive,and in cases of hematopathy as hemophilia, some authors [14]recommand to postpone the surgery because haematoma could be absorbedspontaneousely.

General anesthesia must maintain haemodynamic stability to avoidthe deterioration of the spinal cord perfusion. A high blood pressure isalso maintained in preeclamptic patients [6,7], use of vasoactive drugsis possible. Tracheal intubation is a very important and a difficult momentbecause of the adrenergic effects and spinal movements, then weavoid hyperextension of the neck.

Spinal or epidural anesthesia are not a good choice in this case,because of medullar damages (medicolegal problems) and bleedingtendencies. In any case: laminectomy needs general anesthesia.

In obstetric patients, the holes between vertebrae could be closedand blood give medullar compression because of epidural venous hyperpression.

In these neurological complications, the RMI is the preferred investigationsince it can confirm the diagnosis of epidural haematoma,its size, its localisation and its extension [4,12,13]. It’s also the first examinationto realize during the postoperative period to envisage ulteriorprognosis: persistent bleeding, spinal characteristics and sequellaes.

Lack of recovery in this patient after decompresion may have pooroutcome, patient would need high income level health care to preventurinary tract infections, bedsores and deep vein thrombosis. It’s thusimportant for clinicians to recognize the symptoms and signs of medullarycompression to ovoid the therapeutic delay of which can result,like the case of our patient, a severe neurological deficit.

Conclusion

Although the epidural haematoma is rare during pregnancy, physiciansmust recognize the symptoms of spinal compression and rememberthat severe pain in the spinal areas must be evaluated with anurgent RMI. Precise diagnosis without delay are essential to avoid neurologicalsequellaes. Laminectomy is the most urgent posture to carryout as soon as possible.

The anesthetist must be careful in order not to aggravate the neurologicalstatus of the patient and to contribute to the birth of a newbornunder the best conditions.